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Fractionated stereotactic radiation therapy for adrenal metastases: contributing to local tumor control with low toxicity

Fraktionierte stereotaktische Strahlentherapie bei Nebennierenmetastasen: Beitrag zur lokalen Tumorkontrolle mit geringer Toxizität

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Abstract

Purpose

To report on the Erlangen (UK-Er) experience with linear accelerator stereotactic body radiation therapy (LINAC SBRT) for adrenal metastasis from various primary tumors.

Materials and methods

33 patients were treated. Primary sites included lung (n = 19), melanoma (n = 8), colorectal (n = 2), hepatocellular (n = 1), esophageal (n = 2), and breast cancer (n = 1). 14 patients were treated palliatively, 19 patients were treated with local curative intent.

Radiation treatment

Treatment planning was done based on an exhale, mid-ventilation, and inspiration CT series. Further planning CTs were done to check for the correctness of the breathing pattern. Irradiation was performed using a NOVALIS (Varian, Palo Alto, CA, USA; Brainlab AG, München, Germany) linear accelerator. The isocenter was verified before each treatment session using the BrainLab ExacTrac® (Brainlab AG, München, Germany) system to minimize setup errors. Dose was prescribed to the planning target volume (PTV) surrounding 90% isodose.

Follow-up

Depending on their overall performance status and prognosis, patients received clinical check-ups and radiological imaging. Median follow-up was 11 months.

Statistical analysis

IBM SPSS v. 24 was used for univariate analysis using Kaplan–Meier curves, nonparametric Kruskal–Wallis test, and the chi-square test for frequency distributions. Toxicity was graded according to NCI CTCAE v4.0. Depending on radiologic imaging, patients were classified as stable, regression, and progression.

Results

Median survival was 11 months, median PFS was 5 months. Median local failure-free survival was 21 months. Patients who were treated with curative intent showed a better survival curve (p < 0.0001) and PFS (p = 0.004). BED ranged from 42 to 108.8 Gy, median BED was 67.2 Gy. Three BED groups were formed. Overall survival curves differed significantly (p = 0.046), favoring the high-dose group. 21 patients were free from any adverse events or discomfort. In 7 cases, a grade I toxicity was noted.

Zusammenfassung

Zielsetzung

Eine retrospektive Analyse der Erlanger Erfahrungen der LINAC-SBRT von Nebennierenmetastasen verschiedener Primärtumoren.

Material und Methoden

Es wurden 33 Patienten behandelt. Der Primarius war: Lunge (n = 19), Melanom (n = 8), kolorektale Entitäten (n = 2), HCC (n = 1), Ösophaguskarzinom (n = 2) und Mammakarzinom (n = 1). Mit palliativer Intention wurden 14 Patienten, mit lokaler kurativer Absicht wurden 19 Patienten behandelt.

Bestrahlungsplanung

Die Behandlungsplanung wurde basierend auf einer Exspirations‑, Atemmittellage- und Inspirations-CT-Serie durchgeführt. Mit weiteren Planungs-CTs wurde die Korrektheit des ermittelten Atemmusters überprüft. Die Bestrahlung erfolgte mit einem NOVALIS-Linearbeschleuniger (Varian, Palo Alto, CA, USA; Brainlab AG, München, Deutschland). Isozentrumsverifikationen erfolgten vor jeder Behandlungssitzung mit dem BrainLab ExacTrac®-System (Brainlab AG, München, Deutschland). Die Dosis wurde auf die das Zielvolumen (PTV) 90 % umhüllende Isodose verschrieben.

Verlauf

Abhängig vom Allgemeinzustand und der Prognose erhielten die Patienten klinische Untersuchungen und radiologische Bildgebungen. Das mediane Follow-up betrug 11 Monate.

Statistische Analyse

Es wurde IBM SPSS v. 24 benutzt. Es erfolgten univariate Analysen mit Kaplan-Meier-Kurven, dem nichtparametrischen Kruskal-Wallis-Test und dem Chi-Quadrat-Test für Häufigkeitsverteilungen. Die Toxizität wurde nach NCI CTCAE v4.0 bewertet. Abhängig von der radiologischen Bildgebung erfolgte die Einteilung in die Gruppen mit stabilem Befund, Regression oder Progression.

Ergebnisse

Das mediane Überleben betrug 11 Monate, das mediane PFS 5 Monate. Das mediane Überleben der lokalen Kontrolle lag bei 21 Monaten. Patienten, die in kurativer Absicht behandelt wurden, zeigten eine bessere Überlebenskurve (p < 0,0001) und PFS (p = 0,004). Die BED lag im Bereich von 42–108,8 Gy, der Median bei 67,2 Gy. Es wurden 3 BED-Gruppen gebildet. Die Kurven unterschieden sich signifikant (p = 0,046), mit einer besseren Überlebenskurve der Hochdosisgruppe. Nebenwirkungs- und beschwerdefrei waren 21 Patienten. In 7 Fällen wurde ein Toxizitätsgrad I festgestellt.

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Authors and Affiliations

  1. Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nuremberg, Universitätsstraße 27, 91054, Erlangen, Germany

    Kim Burjakow,  Rainer Fietkau,  Florian Putz,  Nils Achterberg &  Sebastian Lettmaier

  2. Department of Radiation Oncology, Friedrich-Schiller-University Jena, Bachstraße 18, 07743, Jena, Germany

    Stefan Knippen

Authors
  1. Kim Burjakow
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  2. Rainer Fietkau
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  4. Nils Achterberg
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  5. Sebastian Lettmaier
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Corresponding author

Correspondence to Stefan Knippen.

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Conflict of interest

K. Burjakow, R. Fietkau, F. Putz, N. Achterberg, S. Lettmaier, and S. Knippen declare that they have no competing interests.

Ethical standards

All procedures performed were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. For this retrospective study, formal consent is not required.

Additional information

K. Burjakow and S. Knippen contributed equally to this work.

The present work was performed in fulfillment of the requirements for obtaining the degree “Dr. med.” of K. Burjakow.

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Burjakow, K., Fietkau, R., Putz, F. et al. Fractionated stereotactic radiation therapy for adrenal metastases: contributing to local tumor control with low toxicity. Strahlenther Onkol 195, 236–245 (2019). https://doi.org/10.1007/s00066-018-1390-3

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